The present invention relates to the use of nicergoline in the treatment of the pyramidal spasticity of neurological diseases involving an attack of the pyramidal pathway.
Spasticity is among the clinical traits of neurological diseases which have in common an attack of the pyramidal pathway, such as, for example, amyotrophic lateral sclerosis, progressive spinal muscular atrophy, infantile muscular atrophy, primary lateral sclerosis and cerebrovascular accidents.
Nicergoline, or (8xcex2)-10-methoxy-1,6-dimethylergoline-8-methanol-5-bromonicotinate (Sermion(copyright)), in particular has xcex1-blocking and xcex12-adrenolytic properties (CARPENE C. et al., J. Pharmacol, 14, 57-66 (1983)), anti-ischemic properties (CAHN R. et al., Chem. Abstracts, 107, 228784x (1987); UEDAT et al., Chem. Abstracts, 118, 225224f (1993)), anti-calcium properties (TAKAHASHI K. et al., Br. J. Pharmacol., 100, 705-710 (1990)), antioxidant properties (TANAKA M. et al., Neurosci. Let., 248, 67-72 (1998)) and antithrombotic properties (Chem. Abstracts 105, 54314k (1986)). It improves the memory and the learning capacity (Chem. Abstracts, 113, 52358u (1990); Chem. Abstracts, 111, 108396h, 1989; Chem. Abstracts, 109, 86208c, 1988; Chem. Abstracts, 106, 12788e, 1987; Chem. Abstracts, 115, 198237s, 1991).
It has now been found that nicergoline reduces the pyramidal spasticity of neurological diseases involving an attack of the pyramidal pathway and, in particular, of the spasticity during amyotrophic lateral sclerosis, progressive spinal muscular atrophy, infantile muscular atrophy, primary lateral sclerosis and cerebrovascular accidents.
Amyotrophic lateral sclerosis (ALS), also known as Charcot""s disease and Lou Gehrig""s disease, was described for the first time by Charcot in 1865. ALS is a fatal disease resulting from degeneration of the motor neurones. The disease is accompanied by a progressive paralysis, leading to the loss of the motor and respiratory functions and then to death within a period of two to eight years from the appearance of the first symptoms.
Stiffness is among the characteristic clinical traits of this condition. Its degree is variable and it is common to find that there are very stiff patients opposite patients who have little or no stiffness.
This stiffness is generally related to hypertonia (or contracture or spasticity) of the pyramidal syndrome and it is common to consider it as being due to the exclusive attack of the pyramidal pathway.
Clinically, however, it is not always easy to relate the stiffness observed to pyramidal attack alone.
The reason for this is that it is necessary to distinguish between pyramidal stiffness (or contracture or spasticity) and extrapyramidal stiffness (or rigidity).
Pyramidal contracture (increase in the motor tonus, known as Ch. Foix tendon reflexes) is clinically elastic, it becomes reinforced as the muscular insertion points become separated and it is exaggerated with the speed of movement of the limb and gives the mobilized limb a primitive attitude. It predominates on the flexors in the upper limbs and on the extensors in the lower limbs, with a predominance on the distal muscles.
Extrapyramidal rigidity (exaggeration of the Ch. Foix xe2x80x9cposturereflexxe2x80x9d plastic tonus), on the other hand, is a sensation of waxy elastic resistance, which is attenuated by repeated gentle passive mobilization. It affects all muscles, predominantly the proximal (rhizomelic) muscles. The tonus of the limbs is exaggerated during passive shortening of the muscle defining the over excitation of the Ch. Foix posture reflexes (Strumpell""s fixing rigidity). It tends to fix the limb in the position in which the observer has set it. In this respect, it is similar to phenomena of catatonia and catalepsy.
Finally, these changes in tonus should be combined with oppositional rigidity or Gegenhalten""s rigidity which more reflects a frontal attack. It is similar to extrapyramidal rigidity, but differs therefrom by its fluctuating nature and by its exaggeration when the patient attempts to relax.
A certain amount of data argues in favor of attack of the extrapyramidal system in patients suffering from ALS.
In addition to the known association of ALS and Parkinson""s disease (in particular in Guam""s anatomo-clinical complex), various anatomo-clinical studies have objectivized an attack of the central grey matter. As early as 1925, I. Bertrand and L. Van Bogaert (Rev. Neurol., 32, 779-806 (12925)) reported a diffuse attack of the cerebral cortex and of the central grey matter in patients suffering from ALS. In 1972, P. Castaigne et al. (Rev. Neurol., 127, 401-414 (1972)) noted an attack of the central grey matter in 16 out of 19 xe2x80x9catypicalxe2x80x9d cases of ALS, although there did not appear to be any clinical extrapyramidal signs in these patients. Isolated cases of ALS with attack of the substantia nigra have also been reported (S. M. Chou, Dekker pub. pp. 133-181 (1992)). By means of a PET scan with 6-fluorodopa, Takahashi et al. (J. Neural. Transm., 5, 17-26 (1993)) showed a decrease in the uptake of fluorodopa in all patients, despite the absence of a clear clinical sign of attack of the extrapyramidal system. This decrease appears to be accentuated gradually over time in the course of the disease.
Clinical experience shows that most stiff patients have a mixed stiffness: pyramidal and extrapyramidal. An important argument in favor of a probably mixed origin of the stiffness observed in patients suffering from ALS is that this symptom is inaccessible or relatively inaccessible to the muscular relaxant treatments usually used in pyramidal spasticity (baclofen, benzodiazepines and dantrolene).
The distinction between rigidity and spasticity is not only of descriptive importance, but is also of importance in the treatment of these patients. The reason for this is that stiffness is a factor that is probably xe2x80x9cfavorablexe2x80x9d in the vital prognosis, but definitely xe2x80x9cunfavorablexe2x80x9d in the functional prognosis since it is inaccessible or relatively inaccessible to the usual muscular relaxants, even at the price of a considerable increase in doses (occasionally 180 mg/day of baclofen).
A descriptive study on 9 patients suffering from ALS was carried out. The main criterion defined is the stiffness, measured using a visual analog scale (VAS), of 100 mm, or the individual rates by self-assessment the severity of the stiffness perceived.
To date, only riluzole (2-amino-6-trifluoro-methoxybenzothiazole) is sold, under the name Rilutek(copyright), for the treatment of amyotrophic lateral sclerosis. Riluzole mainly makes it possible to slow down the progression of the disease, but has no effect on the spasticity.
The patients receive 100 mg/day of riluzole and 15 mg IV of nicergoline on the first day and 30 mg IV on the next 4 days. The duration of infusion was more than 4 hours to avoid any risk of hypotension.
The measurement was carried out before and after administration of nicergoline.
The results are as follows (meanxc2x1standard deviation, in mm):
The stiffness before administration of nicergoline is 67.33xc2x125.
The stiffness 4 days later (from 4 to 8 d) is 48.11xc2x119.
The intra-individual difference is 19.22xc2x120.5 (95% I=3.44xc2x135; range=xe2x88x928 to +57).
The comparison at a zero difference is significant (t=2.809; p (2xcex1)=0.0229).
The test of deviation from a normal distribution is non-significant.